Nursing Elites

1. The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

• A. a vector.
• B. a source, like contaminated water.
• C. food.
• D. the respiratory system.

Correct answer: D

Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.

2. A client with dumping syndrome should ___________ while a client with GERD should ___________.

• A. lie down 1 hour after meals; sit up at least 30 minutes after meals
• B. sit up 1 hour after meals; lie flat 30 minutes after meals
• C. sit up after meals; sit up after meals
• D. lie down after meals; lie down after meals

Correct answer: A

Rationale: Clients with dumping syndrome should lie down after eating to decrease the symptoms of dumping syndrome, which include rapid gastric emptying leading to various gastrointestinal symptoms. On the other hand, clients with GERD should sit up at least 30 minutes after meals to prevent the backflow of stomach acid into the esophagus. This position helps reduce symptoms by allowing gravity to keep the stomach contents in place, minimizing the chances of reflux. Therefore, the correct answer is to lie down 1 hour after eating for dumping syndrome and to sit up at least 30 minutes after eating for GERD. Choices B, C, and D are incorrect because they do not accurately reflect the appropriate positioning for each condition.

3. Who is responsible for obtaining the signature from the client on the informed consent?

• A. the staff nurse
• B. the charge nurse
• C. the LPN
• D. the physician

Correct answer: D

Rationale: The correct answer is the physician. It is the physician's responsibility to ensure that the client provides informed consent by obtaining their signature. While nurses play a crucial role in the healthcare team, their responsibility lies in verifying that the consent process has been completed correctly and advocating for the client. The staff nurse, charge nurse, and LPN do not have the authority to obtain the client's signature on the informed consent form, as this is within the scope of practice of the physician.

4. While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?

• A. Contact the nursing supervisor.
• B. Tell the staff member that she is not allowed to administer medications.
• C. Ask the staff member how much alcohol she has consumed.
• D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.

Correct answer: A

Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.

5. When providing perineal care to a female client, how should the nurse perform the procedure?

• A. with gloves, washing the perineal area from front to back
• B. without gloves, having the client perform all care
• C. with gloves, washing the perineal area from back to front
• D. without gloves, pouring water from a sterile bottle

Correct answer: A

Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention. Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.

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